Healthcare Provider Details

I. General information

NPI: 1295068757
Provider Name (Legal Business Name): GRACE HILL NEIGHBORHOOD HEALTH CTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2009
Last Update Date: 09/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 LEMP AVE
SAINT LOUIS MO
63104-2700
US

IV. Provider business mailing address

2220 LEMP AVE
SAINT LOUIS MO
63104-2700
US

V. Phone/Fax

Practice location:
  • Phone: 314-814-8556
  • Fax: 314-814-8542
Mailing address:
  • Phone: 314-814-8556
  • Fax: 314-814-8542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number2009014930
License Number StateMO

VIII. Authorized Official

Name: MARY LUCCA
Title or Position: LICENSED DIETITIAN
Credential:
Phone: 314-814-8556